A statement that the hospital or health care system will use emergency department utilization data to identify recipients of Medical Assistance to receive intensive care coordination to reduce use of the emergency department by those Medical Assistance recipients.

The method the hospital or health care system uses to identify for intensive care coordination a Medical Assistance recipient who uses the emergency department frequently. The hospital or health care system shall specify how it defines frequent emergency department use and may use criteria such as whether a recipient of Medical Assistance visits the emergency room 3 or more times within 30 days, 6 or more times within 90 days, or 7 or more times within 12 months.

A description of the hospital’s or health care system’s intensive care coordination team consisting of health care providers other than solely physicians, such as nurses; social workers, case managers, or care coordinators; behavioral health specialists; and schedulers.

A statement that the hospital or health care system will provide to a Medical Assistance recipient enrolled in intensive care coordination through the hospital or health care system all of the following, as appropriate to his or her care: a. Discharge instructions and contacts for following up on care and treatment. b. Referral information. c. Appointment scheduling. d. Medication instructions. e. Intensive care coordination by a social worker, case manager, nurse, or care coordinator to connect the Medical Assistance recipient to a primary care provider or to a managed care organization. f. Information about other health and social resources, such as transportation and housing.

A statement that the hospital or health care system agrees to share information with the state-designated entity for health information exchange or with another appropriate data-sharing mechanism. For Medical Assistance recipients who are enrolled in managed care, a hospital or health care system shall agree to share, at the request of the managed care organization, applicable discharge instructions, current medication information, and care plan information as permitted by s. 146.816 (2) with the managed care organization in which the recipients are enrolled. The hospital or health care system may satisfy the requirement under this subdivision to share information with a managed care organization by providing the information to the state-designated entity for health information exchange or by providing the information to the managed care organization using another appropriate information-sharing mechanism agreed upon by the hospital or health care system and the managed care organization.

The outcomes intended to result from intensive care coordination by the hospital or health care system. Outcomes for a Medical Assistance recipient during a 6-month or 12-month period may include successful connection to primary care or a managed care organization as evidenced by 2 or 3 primary care appointments, successful connection to behavioral health resources and alcohol and other drug abuse resources, as needed, or a decrease in use of the emergency room.